Provider Demographics
NPI:1134102734
Name:KELLEY, RAYMOND
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SPRING FOREST RD STE 130
Mailing Address - Street 2:7TH FLOOR
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-1004
Practice Address - Country:US
Practice Address - Phone:352-273-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201702089207L00000X
FLME89036207L00000X
WA00038263207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275245000Medicaid